Horowitz Lyme MSIDS Questionnaire

Horowitz Lyme-MSIDS Questionnaire

The Horowitz Lyme-MSIDS Questionnaire is not intended to replace the advice of your own physician or other medical professional. You should consult a medical professional in matters relating to health, and individuals are solely responsible for their own healthcare decisions regarding the use of this questionnaire. It is intended for informational purposes only and not for self-treatment or diagnosis. © 2014 Richard I. Horowitz, M.D.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Please answer the following questions with how you have been feeling over the last three months.

SECTION 1: SYMPTOMS

	None	Mild	Moderate	Severe
1. Unexplained fevers, sweats, chills, or flushing
2. Unexplained weight change; loss or gain
3. Fatigue, tiredness
4. Unexplained hair loss
5. Swollen glands
6. Sore throat
7. Testicular or pelvic pain
8. Unexplained menstrual irregularity
9. Unexplained breast milk production; breast pain
10. Irritable bladder or bladder dysfunction
11. Sexual dysfunction or loss of libido
12. Upset stomach
13. Change in bowel function (constipation or diarrhea)
14. Chest pain or rib soreness
15. Shortness of breath or cough
16. Heart palpitations, pulse skips, heart block
17. History of a heart murmur or valve prolapse
18. Joint pain or swelling
19. Stiffness of the neck or back
20. Muscle pain or cramps
21. Twitching of the face or other muscles
22. Headaches
23. Neck cracks or neck stiffness
24. Tingling, numbness, burning, or stabbing sensations
25. Facial paralysis (Bell’s palsy)
26. Eyes/vision: double, blurry
27. Ears/hearing: buzzing, ringing, ear pain
28. Increased motion sickness, vertigo
29. Light-headedness, poor balance, difficulty walking
30. Tremors
31. Confusion, difficulty thinking
32. Difficulty with concentration or reading
33. Forgetfulness, poor short-term memory
34. Disorientation: getting lost; going to wrong places
35. Difficulty with speech or writing
36. Mood swings, irritability, depression
37. Disturbed sleep: too much, too little, early awakening
38. Exaggerated symptoms or worse hangover from alcohol

	No	Yes
Did you answer "Severe" to all of the symptoms above?

SECTION 2: MOST COMMON LYME SYMPTOMS

	None	Mild	Moderate	Severe
39. Fatigue
40. Forgetfulness, poor short-term memory
41. Joint pain or swelling
42. Tingling, numbness, burning, or stabbing sensations
43. Disturbed sleep: too much, too little, early awakening

SECTION 3: LYME INCIDENCE

	No	Yes
44. You have had a tick bite with no rash or flulike symptoms. 3 points
45. You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms. 5 points
46. You live in what is considered a Lyme-endemic area. 2 points
47. You have a family member who has been diagnosed with Lyme and/or other tick-borne infections. 1 point
48. You experience migratory muscle pain. 4 points
49. You experience migratory joint pain. 4 points
50. You experience tingling/burning/numbness that migrates and/or comes and goes. 4 points
51. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia. 3 points
52. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder. 3 points
53. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture). 5 points

SECTION 4: OVERALL HEALTH

	0–5 days	6–12 days	13–20 days	21–30 days
54. Thinking about your overall physical health, for how many of the past thirty days was your physical health not good?
55. Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good?

Horowitz Lyme-MSIDS Questionnaire